Inquiries Focused On Osteopathic Physician

When Ghia Alberto showed up at Miami Heights Elementary School one morning in November 1992, her first-grade teacher noticed something strange about the pretty, dark-haired girl.

Ghia's face looked puffy, particularly around her cheeks.

The teacher mentioned the change to Ghia's mom, Annette Betancourt, who also had noticed the swelling. Betancourt agreed that if it didn't subside, she'd take the child to the doctor after school.

But Ghia looked better later in the day, so Betancourt decided to hold off, the woman testified in a court deposition.

The next morning, a Saturday, the 7-year-old woke up feeling terrible. She was nauseated and vomiting. Her face was swollen and her head hurt.

"Mommy, I have a headache," she kept saying, according to her mother. Betancourt said she gave Ghia an over-the-counter remedy and tried, with no luck, to get her to eat something.

At that point she called the family's Medicaid HMO doctor, Jules Minkes, an osteopathic physician, at Suburban Medical Plan.

Suburban was a Medicaid-only HMO with fewer than 300 members. The HMO lost its Medicaid contract earlier this year after it failed to take steps that would allow it to enroll commercial members. It is appealing, according to state insurance regulators.

The care Ghia Alberto received from the plan is the subject of a lawsuit pending in Dade Circuit Court. Betancourt says Minkes failed to properly diagnose the little girl's ailment, which led to her death.

Minkes, at the time owner of Suburban Medical Plan, tells a far different story. He denies any negligence and says he is fighting the malpractice lawsuit vigorously.

"I treated her properly," Minkes said. "We did everything we could."

Cases such as Alberto's, whatever their outcome, rarely are investigated by state quality reviewers at the Agency for Health Care Administration.

Although the agency runs a toll-free HMO complaint hotline, for example, Medicaid HMO patients seem to be unaware of its existence.

Last year, the hotline received 436 complaints about the quality of care in 30 health plans. Not one involved a Medicaid-only HMO.

The agency's quality assurance chief, Robert Pannell, said the reason isn't that Medicaid HMOs are problem-free. It's that his unit spends almost all of its time reviewing complaints about commercial HMOs and rarely is asked by health officials to investigate Medicaid HMO problems.

The Medicaid HMO unit has had no medical staff to look into quality complaints and has relied largely on the plans to police themselves.

However, the health agency is in the process of merging quality enforcement for all types of HMOs.

"This will allow us to better coordinate our reviews of health plans in Florida regardless of payer and develop more focused reviews when areas of concern are discovered," agency director Doug Cook wrote in a letter to the Sun-Sentinel.

The Alberto case remains to be resolved.

Minkes examined the child and said she had a stomach virus. He told Betancourt to keep her on a non-prescription medicine for upset stomach and a liquid diet, according to his handwritten notes.

But the next morning, Ghia wasn't feeling any better. She continued to vomit and her headache persisted.

Betancourt was getting worried. She had Minkes paged. He returned the call and told her to wait until the next day for an appointment, according to her testimony.

About 2 a.m. Monday, Betancourt discovered her daughter lying on the floor of her bedroom, paralyzed on the left side of her body and unable to see.

Betancourt picked up the child and drove her to Deering Hospital, where her condition worsened. Later, she was transported to Miami Children's Hospital. On the way, she suffered a series of seizures. By 5:45 a.m. she was declared brain dead.

Two days later, on Nov. 18, 1992, doctors disconnected Ghia from the life support machine. An autopsy revealed the child had encephalitis, an inflammation of the brain.